Health insurance billing: in-network or out-of-network

One of the most common questions I hear as an expert in the implementation of medical/dental billing to dental offices is: “Do we need to be networked to bill medical insurance? There are several things to consider with this question, but the answer mainly depends on the answer to the following question: What type of medical insurance policies do you want to charge?

Types of insurance

There are several types of insurance. The most common are Health Maintenance Organizations (HMOs), Exclusive Provider Organizations (EPOs), and Preferred Provider Organizations (PPOs).

HMO and EPO are similar in that you have to be in-network (IN) to bill these plans, as they don’t allow the patient to see a provider who is out of their network (OON). These plans will pay $0 for the services you perform if you are out of network.

Sometimes, and only sometimes, will they allow the patient to see an OON provider if they are in an emergency situation and need to be seen. An example is a patient suffering from extreme pain due to an abscessed (infected) tooth or some kind of trauma. The HMO/EPO will most likely initially deny services to an out-of-network provider; however, they may pay if you appeal the claim.

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These plans will make you work to get paid, if they agree to pay at all. I advise OON firms to avoid charging for these types of restricted plans.

Most of the population has PPO type medical plans. PPO plans provide in-network and out-of-network benefits to their insured patients. There is a difference in how benefits are paid to an IN provider vs. OON. For example, if a procedure is paid 80% to an IN provider, it is often paid 60% or less to an OON provider.

Franchise is another important factor. If the patient has a $1,000 deductible for IN, it will likely be double that, or $2,000, for an OON provider. It is important to know that not all procedures apply to the franchise. Assessments are an example. I often see a copay applied, the medical carrier pays and nothing goes towards the deductible.

If you want to play it safe, tell your patients that once their deductible is reached, their doctor will start paying. You will be surprised how many procedures do not apply to the franchise at all. A big variable will be the quality of the plan. Just as there are good and not so good dental policies, the same is true for medical care. You really get what you pay for.

Most practices don’t notice this reduction in benefits because the allowances (amount allowed for payment for a procedure/service) are much higher than the amounts allowed for dental care (which is on your contractual fee schedule ). Most procedures cost more than double what dental policies pay.

Accreditation with medical insurance

The accreditation process to enter medical insurance is similar to accreditation with dental plans. It’s important to make sure the medical carrier understands that you want to get into medical, not dental care, and that you provide many services that don’t involve teeth and are more medical in nature. However, you will find that many medical plans only allow oral surgeons in.

Blue Cross Blue Shield (BCBS) is one of the largest medical carriers in the United States, but is completely different in each state, unlike Aetna, Cigna, and United Healthcare. In some states, BCBS offers dentists entry.

Many dental practices are unaware that in some states, if you are dental IN, you are automatically medical IN. In this scenario, you could easily bill the doctor and be reimbursed more than double for your services. It also saves patients dental benefits for dental type procedures. You can bill both medical and dental expenses; these are separate policies that your patients pay for and receive benefits for.

Medical billing is here to stay. There are many services you provide that can be billed to doctors, such as assessments, surgeries, frenectomies, and sleep or TMJ treatments. Whether you are IN or OON, being strategic in your approach will increase your practice’s collections and reduce your patients’ out-of-pocket expenses.

Editor’s note: This article originally appeared in the June 2022 print edition of Dental economy magazine. Dentists in North America can take advantage of a free print subscription. Register here.

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